Provider Demographics
NPI:1326261843
Name:SENATOBIA CHILDRENS CLINIC PC
Entity Type:Organization
Organization Name:SENATOBIA CHILDRENS CLINIC PC
Other - Org Name:DESOTO CHILDRENS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DESH
Authorized Official - Middle Name:DEEPAK
Authorized Official - Last Name:SIDHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-349-6577
Mailing Address - Street 1:7276 SOUTHCREST PKWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671
Mailing Address - Country:US
Mailing Address - Phone:662-349-6577
Mailing Address - Fax:662-349-6562
Practice Address - Street 1:7276 SOUTHCREST PKWY
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671
Practice Address - Country:US
Practice Address - Phone:662-349-6577
Practice Address - Fax:662-349-6562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015155Medicaid